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New York is planning a huge change in the delivery of Medicaid home care services. The 2011 budget mandates that as of April 1, 2012, everyone now receiving community-based long-term care services -- particularly personal care/home attendant services and long-term Certified Home Health Agency services -- will be required to enroll in a Managed Long-Term Care (MLTC) plan, and that plan will now control access to and utilization of these home care services and other long-term care services. These MLTC plans will NOT control all primary and acute medical care paid for by Medicare and Medicaid -- so the consumer may still go to the doctor and hospital of their choice. But.. there are certain Medicaid services that are within the "benefit package" of the MLTC plan (audiology, optometry, podiatry, durable medical equipment, eyeglasses, hearing aides, medical transportation). What makes it more confusing is that there are different types of Managed Care plans that DO control all primary and acute medical care paid for by Medicare and Medicaid -- it will not be mandatory for consumers to join these plans, but they will have the option to do so. This article explains the different plans and the status of "mandatory" implementation in NYS. Background on Managed Long Term CareMLTC is different from other types of long-term care in that it is financed by capitated payments to managed care organizations to provide home care and certain other medical services. (at least vis-à-vis Personal Care Assistance and Certified Home Health Agency services) is that MLTC includes care management and integrated care delivery. Consumers must receive long-term care services through the network of providers that contracts with the plan. There are two basic models of managed long-term care in New York State: (I) Fully Capitated plans, with 3 variations of plans (PACE) and (II) Partially Capitated plans - Managed Long-Term Care Plans. It is only the latter type, the partially capitated plans, that will become mandatory, but consumers will be receiving information about and the opportunity to enroll in all of the plans, so it's important to know the differences. A summary chart is posted here. I. "Full Capitation" - all Medicare & Medicaid services - 3 types of these plans -- (1) PACE "Programs of All-Inclusive Care for the Elderly" plans and (2) MEDICAID ADVANTAGE PLUS [MAP] Both PACE and Medicaid Advantage Plus provide BOTH primary medical care AND long-term care services, including all services paid for by MEDICARE and MEDICAID. PACE Members must be age 55 and older, and all members must be otherwise eligible for nursing home admission. The PACE or MAP Plus plan receives a "capitated" monthly payment to cover all Medicare and Medicaid services. PACE or MAP Plus members are required to use PACE network physicians, home care providers, hospitals, and other providers. The PACE or MAP Plus plan is responsible for directly providing or arranging all primary, inpatient hospital and long-term care services required by a member and provides on-going care management. (3) MEDICAID ADVANTAGE PLANS are a slight variation on the MEDICAID ADVANTAGE PLUS plans described above. They provide and control access to all primary medical care paid for by MEDICARE and MEDICAID, EXCEPT that they do not cover most long-term care services by either Medicaid or Medicare. II. Managed Long-Term Care Plans - "MLTC" - "Partial capitation" - Certain Medicaid services only (1) Managed long-term care plans provide long-term care services (like home health, adult day care, and nursing home care) and ancillary and ambulatory services (including dentistry, optometry, eyeglasses, and medical equipment), and receive Medicaid payment only. Members continue to receive their regular Medicaid and Medicare cares to obtain services from their primary care physicians and inpatient hospital services -- the MLTC plan does not control or provide any Medicare services, and does not control or provide most primary MEDICAID care. Members must be eligible for nursing home admission. While several plans in New York State enroll younger members, most managed long-term care plan enrollees must be at least age 65. See this chart summarizing the differences between the 4 types of managed care plans described above. The chart also includes a 5th type of managed care plan - Medicaid Managed Care - these plans are mandatory for most Medicaid recipients who do NOT have Medicare. The capitated payment they receive covers almost all Medicaid services, with some exceptions of services that are not in the benefit package. (The benefit package has always included CHHA home health aide services, but before August 1, 2011 did not include Medicaid personal care/home attendant services - members had accessed them separately through their CASA or local DSS offices. As of August 1, 2011, the 6000 members in these plans who receive Medicaid personal care services began receiving them subject to approval by their managed care plans. See more in this article. and this article explaining that Medicaid managed care enrollees as of October 1, 2011 must now obtain prescription drugs through their Medicaid managed care plans, rather than on a fee-for-service basis. LISTS OF MLTC and Related PLANS in NYS AND CURRENT MLTC ENROLLMENT
Status of Mandatory Enrollment in Managed Long Term Care - Law Requires to Become Mandatory in April 2012But CMS has not granted a waiver as of Feb. 3, 2012 so delay is likely, but unknown how long. Until April 1, 2012, enrollment in any of the 4 types of managed care plans above has been voluntary. One who might otherwise choose Medicaid personal care/home attendant or Medicaid certified home health aide (CHHA) care could alternately enroll in an MLTC plan which would then authorize these home care services, in addition to adult day care, PERS, and the other services above. Since enrollment has been voluntary, an individual could, in any month, disenroll from the plan and switch to a different Medicaid home care program, such as personal care approved by the local HRA CASA. On April 1, 2012, if approved by the federal government, every personal care (home attendant) recipient who needs these services for more than 120 days will be required to enroll in one of the MLTC plans. Since NYS counties outside of NYC do not have enough of these plans to absorb this population, the mandatory enrollment wlll begin only in NYC. No date is set yet for mandatory enrollment upstate. In NYC, all new applicants for personal care/ home attendant care after April 1, 2012 will be required to enroll in an MLTC plan -- they will no longer get these services approved through the HRA CASA offices. Since it will be impossible to enroll all 40,000+ current personal care/home attendant recipients in MLTC plans at once, they will be gradually enrolled over a 3-year period. Click here for the State's Draft Enrollment Planfor enrolling 2000 current recipients per month. The requirement for mandatory enrollment in MLTC plans was enacted in the NYS budget effective April 1, 2011. DOH requested CMS approval for this change in the same April 13, 2011 1115 waiver request with which it requested expansion of Medicaid managed care, described above. See http://www.health.ny.gov/health_care/managed_care/appextension/ -- all under the first heading labeled Amendment to Implement Medicaid Redesign Team Changes to the 1115 Waivers. The details on the Managed Long Term Care expansion request begin at Page 3 of the Summary of MRT changes. MLTC plans will be required to offer Consumer-Directed Personal Assistance Program (CDPAP) services to its members, though it is unclear how this will be implemented.
WHICH PLANS WILL CLIENTS NOW RECEIVING PERSONAL CARE BE ASSIGNED TO in April 2012? Under mandatory enrollment, individuals will receive a packet by mail giving the choices of plans, and affording 30 days to select a plan. If the individual does not select a plan, s/he will be assigned to one randomly. Clients could be assigned only to the "Partial Capitation" Managed Long Term Care Plans (MLTC), not to the PACE or Medicaid Advantage Plus or Medicaid Advantage Plus plans, since those control access to Medicare services as well as Medicaid. However, the 2011 NYS budget law gives NYS authority to seek approval from CMS to automatically enroll any Medicaid recipient into a MEDICAID ADVANTAGE (or Medicaid Advantage Plus) plan, if that individual is already enrolled in a MEDICARE ADVANTAGE Plan operated by a company that also has a MEDICAID ADVANTAGE Plan. The chart described above shows which Medicare Advantage plans in each county also have a Medicaid Advantage plan, at least as of June 2011 -- the list will likely grow in the next year. (So.. counseling clients about enrolling in a Medicare Advantage plan for their Medicare services must now take this factor into consideration -- that all access to Medicaid and Medicare doctors, hospitals and other services will now be controlled by the plan). Consumer Concerns on Mandatory Enrollment in Managed Long Term Care
More about Managed Long Term Care in New York State, including History and Appeal RightsThese two articles, written in 2010, are reprinted with permission from publications of the New York State Bar Association. Please note that these articles were written BEFORE state law was enacted in April 2011 that will mandate enrollment into MLTC programs. The switch from voluntary to mandatory enrollment will trigger changes in consumer grievance and appeal procedures, and guidelines for plans. Appeal rights will become more important once enrollment becomes mandatory, since enrollees unhappy with MLTC services will no longer be allowed to freely switch to another Medicaid home care program -- CHHA or personal care, since these services when needed for more than 120 days will only be available through MLTC plans. Medicaid Managed Long Term Care in New York, Part I -- By David Silva, Assistant Director, Selfhelp Community Services Evelyn Frank Legal Resources Program, and David Kronenberg, Goldfarb, Abrandt Salzman & Kutzin, reprinted with permission from: Elder Law Attorney, Winter 2010, Vol. 20, No. 1, published by the New York State Bar Association, One Elk Street, Albany, NY 12207.
Medicaid Managed Long Term Care in New York, Part II -- By David Silva, Assistant Director, Selfhelp Community Services Evelyn Frank Legal Resources Program, and David Kronenberg, Goldfarb, Abrandt Salzman & Kutzin, reprinted with permission from: Elder Law Attorney, Summer 2010, Vol. 20, No. 2, published by the New York State Bar Association, One Elk Street, Albany, NY 12207.
The above articles cite to certain documents posted on the State Dept. of Health website. For convenience, the hyperlinks include:
Newly posted on the DOH website since the articles were written:
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